A randomized trial of vas occlusion versus vasectomy for male contraception

Vasectomy occlusion techniques for male sterilization

BACKGROUND

Vasectomy is an increasingly popular and effective family planning method. A variety of vasectomy techniques are used worldwide, including vas occlusion techniques (excision and ligation, thermal or electrocautery, and mechanical and chemical occlusion methods), as well as vasectomy with vas irrigation or with fascial interposition. Vasectomy guidelines largely rely on information from observational studies. Ideally, the choice of vasectomy techniques should be based on the evidence from randomized controlled trials (RCTs).

OBJECTIVES

The objective of this review was to compare the effectiveness, safety, acceptability and costs of vasectomy techniques for male sterilization.

SEARCH METHODS

In February 2014, we updated the searches of CENTRAL, MEDLINE, POPLINE and LILACS. We looked for recent clinical trials in ClinicalTrials.gov and the International Clinical Trials Registry Platform. Previous searches also included EMBASE. For the initial review, we searched the reference lists of relevant articles and book chapters.

SELECTION CRITERIA

We included RCTs comparing vasectomy techniques, which could include suture ligature, surgical clips, thermal or electrocautery, chemical occlusion, vas plugs, vas excision, open-ended vas, fascial interposition, or vas irrigation.

DATA COLLECTION AND ANALYSIS

We assessed all titles and abstracts located in the literature searches. Two reviewers independently extracted data from articles identified for inclusion. Outcome measures include contraceptive efficacy, safety, discontinuation, and acceptability. Peto odds ratios (OR) with 95% confidence intervals (CI) were used for dichotomous outcomes, such as azoospermia. The mean difference (MD) was used for the continuous variable of operating time.

MAIN RESULTS

Six studies met the inclusion criteria. One trial compared vas occlusion with clips versus a conventional vasectomy technique. No difference was found in failure to reach azoospermia (no sperm detected). Three trials examined vasectomy with vas irrigation. Two studies looked at irrigation with water versus no irrigation, while one examined irrigation with water versus the spermicide euflavine. None found a difference between the groups for time to azoospermia. However, one trial reported that the median number of ejaculations to azoospermia was lower in the euflavine group compared to the water irrigation group. One high-quality trial compared vasectomy with fascial interposition versus vasectomy without fascial interposition. The fascial interposition group was less likely to have vasectomy failure. Fascial interposition had more surgical difficulties, but the groups were similar in side effects. Lastly, one trial found that an intra-vas was less likely to produce azoospermia than was no-scalpel vasectomy. More men were satisfied with the intra-vas device, however.

AUTHORS' CONCLUSIONS

For vas occlusion with clips or vasectomy with vas irrigation, no conclusions can be made as those studies were of low quality and underpowered. Fascial interposition reduced vasectomy failure. An intra-vas device was less effective in reducing sperm count than was no-scalpel vasectomy. RCTs examining other vasectomy techniques were not available. More and better quality research is needed to examine vasectomy techniques.

Effectiveness of vasectomy techniques

The effectiveness of various vasectomy techniques is reviewed, with a focus on methods used for vas occlusion. Spontaneous recanalization of the vas is more common than generally recognized and is often transient. Simple ligation and excision has an unacceptably high risk for failure. Techniques that include cautery seem to have a lower risk for failure than techniques that do not include cautery. There is insufficient evidence to recommend a particular standardized cautery technique, but adding fascial interposition to cautery seems to be associated with the lowest risk for failure.

Vasectomie et chirurgies contraceptives déférentielles : aspects légaux et techniques

OBJECTIVES

To analyse technical innovations, their results and the changing legislation in France concerning sterilizing or contraceptive vas deferens surgery.

MATERIAL AND METHODS

A review of the literature was performed using the key words: male/contraception/vas deferens. From the 332 research articles obtained from PUBMED, we selected 54 articles for their methodological quality and the importance of their results.

RESULTS

Vasectomy remains the only validated vas deferens surgical technique. Although microsurgical reconstructive techniques have improved the vas deferens restoration rate, vasectomy must be considered to be a definitive method of sterilization. The other contraceptive (reversible) vas deferens surgical techniques have not demonstrated sufficient efficacy to be used outside of the context of clinical trials. However the encouraging results ofsome ofthese studies could allow their development in the intermediate term. From a legal point of view, since the reform of sterilizing surgery in Article L2123-1 of the French Public Health Act, vasectomy is now authorized in a regulatory framework.

CONCLUSION

The urology community must take into account progress in the field of contraceptive vas deferens surgical techniques.

Vasectomy occlusion techniques for male sterilization

BACKGROUND

Vasectomy is an increasingly popular and effective family planning method. A variety of vasectomy techniques are used worldwide, including various vas occlusion techniques (excision and ligation, thermal or electrocautery, and mechanical and chemical occlusion methods), as well as vasectomy with vas irrigation or with fascial interposition. Vasectomy guidelines largely rely on information from observational studies. Ideally, the choice of vasectomy techniques should be based on the best available evidence from randomized controlled trials.

OBJECTIVES

The objective of this review was to compare the effectiveness, safety, acceptability and costs of vasectomy techniques for male sterilization.

SEARCH STRATEGY

We searched the computerized databases of CENTRAL, MEDLINE, EMBASE, POPLINE and LILACS. In addition, we searched the reference lists of relevant articles and book chapters.

SELECTION CRITERIA

We included randomized controlled trials comparing vasectomy techniques.

DATA COLLECTION AND ANALYSIS

We assessed all titles and abstracts located in the literature searches. Two reviewers independently extracted data from articles identified for inclusion. Outcome measures include contraceptive efficacy, safety, discontinuation, and acceptability.

MAIN RESULTS

Six studies met the inclusion criteria. One trial compared vas occlusion with clips versus a conventional vasectomy technique. No difference was found in failure to reach azoospermia. Three trials examined vasectomy with vas irrigation. Two studies looked at irrigation with water versus no irrigation, while one examined irrigation with water versus the spermicide euflavine. None found a difference between the groups for time to azoospermia. However, one trial reported that the median number of ejaculations to azoospermia was lower in the euflavine group compared to the water irrigation group. One high-quality trial compared vasectomy with fascial interposition versus vasectomy without fascial interposition. The fascial interposition group was less likely to have vasectomy failure. Fascial interposition had more surgical difficulties, but the groups were similar in side effects. Lastly, one trial found that an intra-vas was less likely to produce azoospermia than was no-scalpel vasectomy. More men were satisfied with the intra-vas device, however.

AUTHORS' CONCLUSIONS

For vas occlusion with clips or vasectomy with vas irrigation, no conclusions can be made as those studies were of low quality and underpowered. Fascial interposition reduced vasectomy failure. An intra-vas device was less effective in reducing sperm count than was no-scalpel vasectomy. Randomized controlled trials examining other vasectomy techniques were not available. More and better quality research is needed to examine vasectomy techniques.

Vasectomy surgical techniques: a systematic review

BACKGROUND

A wide variety of surgical techniques are used to perform vasectomy. The purpose of this systematic review was to assess if any surgical techniques to isolate or occlude the vas are associated with better outcomes in terms of occlusive and contraceptive effectiveness, and complications.

METHODS

We searched MEDLINE (1966-June 2003), EMBASE (1980-June 2003), reference lists of retrieved articles, urology textbooks, and our own files looking for studies comparing two or more vasectomy surgical techniques and reporting on effectiveness and complications. From 2,058 titles or abstracts, two independent reviewers identified 224 as potentially relevant. Full reports of 219 articles were retrieved and final selection was made by the same two independent reviewers using the same criteria as for the initial selection. Discrepancies were resolved by involving a third reviewer. Data were extracted and methodological quality of selected studies was assessed by two independent reviewers. Studies were divided in broad categories (isolation, occlusion, and combined isolation and occlusion techniques) and sub-categories of specific surgical techniques performed. Qualitative analyses and syntheses were done.

RESULTS

Of 31 comparative studies (37 articles), only four were randomized clinical trials, most studies were observational and retrospective. Overall methodological quality was low. From nine studies on vas isolation, there is good evidence that the no-scalpel vasectomy approach decreases the risk of surgical complications, namely hematoma/bleeding and infection, compared with incisional techniques. Five comparative studies including one high quality randomized clinical trial provided good evidence that fascial interposition (FI) increases the occlusive effectiveness of ligation and excision. Results of 11 comparative studies suggest that FI with cautery of the vas lumen provides the highest level of occlusive effectiveness, even when leaving the testicular end open. Otherwise, firm evidence to support any occlusion technique in terms of increased effectiveness or decreased risk of complications is lacking.

CONCLUSIONS

Current evidence supports no-scalpel vasectomy as the safest surgical approach to isolate the vas when performing vasectomy. Adding FI increases effectiveness beyond ligation and excision alone. Occlusive effectiveness appears to be further improved by combining FI with cautery. Methodologically sound prospective controlled studies should be conducted to evaluate specific occlusion techniques further.

Vasectomy occlusion techniques for male sterilization

BACKGROUND

Vasectomy is an increasingly popular and effective family planning method. A variety of vasectomy techniques are used worldwide including various vas occlusion techniques (excision and ligation, thermal or electrocautery, and mechanical and chemical occlusion methods), vas irrigation and fascial interposition. Vasectomy guidelines largely rely on information from observational studies. Ideally, the choice of vasectomy techniques should be based on the best available evidence from randomized controlled trials.

OBJECTIVES

The objective of this review was to compare the effectiveness, safety, acceptability and costs of vasectomy techniques for male sterilization.

SEARCH STRATEGY

We searched the computerized databases the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Popline and LILACS. In addition, we searched the reference lists of relevant articles and book chapters.

SELECTION CRITERIA

We included randomized controlled trials and controlled clinical trials comparing vasectomy techniques.

DATA COLLECTION AND ANALYSIS

We assessed all titles and abstracts located in the literature searches and two reviewers independently extracted articles identified for inclusion. Data were presented in the text of the review. Outcome measures include contraceptive efficacy, safety, discontinuation, and acceptability.

MAIN RESULTS

Two trials compared vas occlusion with clips versus a conventional vasectomy technique; both were of poor quality. Neither trial found a difference between the two groups with regard to the primary outcome of failure to reach azoospermia. Four trials examined vas irrigation: three compared water irrigation with no irrigation and one compared water irrigation with euflavine. All of the trials were of poor quality. None of the trials found a significant difference between the groups with respect to the primary outcome of time to azoospermia. However, one trial found that the median number of ejaculations to azoospermia was significantly lower in the euflavine group compared to the water irrigation group. The one trial that compared vasectomy with fascial interposition versus vasectomy without fascial interposition was a high quality, large study that has only been partially reported at the time of this review. The fascial interposition group was significantly more likely to be related to vasectomy success (azoospermia) at 22 weeks. However, fascial interposition also was associated with significantly more surgical difficulties.

REVIEWERS' CONCLUSIONS

No conclusions can be made about the effectiveness, safety, acceptability and costs of vas occlusion technique or vas irrigation as studies that examined these were of low quality and underpowered. Fascial interposition is associated with improved vasectomy success but is associated with some increased surgical difficulty. Randomized controlled trials examining other vasectomy techniques were not available. More research is required to examine vasectomy techniques.

Nd:YAG coagulation of the verumontanum: an endoscopic attempt at sterilization

In order to develop a new and less invasive method of sterilization in men we performed photocoagulation of the verumontanum in 10 rams, using a Nd:YAG laser, wavelength 1,060 nm. Under general anesthesia a perineal urethro-cutaneous fistula was achieved, and, by means of a 16F laser-endoscope, transurethral coagulation of the ejaculatory ducts, located in the verumontanum, was carried out, using pulses of 1.5 sec in duration and 20-30 W in power. The animals were killed at different postoperative time intervals, ranging from 1 day to 8 weeks. Injection of methylene-blue into the testicular ducts of the resected prostate-bladder specimen and histologic studies of the coagulated tissue revealed that complete bilateral occlusion of the ejaculatory ducts had been achieved in 4 rams. Failures were due to over-extended irradiation of the verumontanum. Except for urinary tract infections occurring in 4 animals, no serious complications were encountered. Further investigations are still necessary to determine the role of lasers in male sterilization.

Sterilization by vas occlusion without transection does not reduce postvasectomy sperm-agglutinating antibodies in serum. A randomized trial of vas occlusion versus vasectomy

The influence of transection of the vasa on the increase in sperm-agglutinating activity in serum after vasectomy was investigated in a prospective randomized study. Sixty-eight males requesting vasectomy were allocated to either of two groups: vas occlusion by tantalum clips without transection of the vasa, or conventional vasectomy by transection and ligation. Sperm-agglutinating antibodies were determined by a micro-agglutination test before and 6 months after vasectomy or vas occlusion. A significant increase in sperm-agglutinating activity in serum after sterilization was found in both groups, but there was no intergroup difference.